Tameside and Glossop Integrated Care NHS Foundation Trust
NHS / Health Body
Action Taken
Following an audit that identified documentation challenges, the Trust has implemented a new patient safety checklist, revised matrons' walk-arounds, redesigned the documentation audit process, and placed documentation reminders on nursing computers. (AI summary)
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Dear Mr Morris, Firstly, on behalf of the Trust, I would like to express my sincere condolences to Mrs. Wood’s family fortheir loss. Following the inquest on 7th October 2025, I note that you raised concerns around documentation, specifically no documentation around sepsis screening prior to Mrs Wood’s discharge from the Emergency Department (ED) on 28th December 2024. Firstly, it is important to note that when patients present to the Emergency Department they are triaged in line the Manchester Triage System, which is a clinical risk management tool used by clinicians worldwide to enable them to safely manage patient flow when clinical need far exceeds capacity. The triage system categorises patients in order of priority and all patients attending the ED should be triaged, or initially assessed, within 15 minutes. As part of this triage, observations are taken using the National Early Earning Score (NEWS) which is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. Mrs. Wood scored a NEWS of 1 and was categorised as a category 3 at the point of triage which therefore did not trigger the sepsis pathway and was in line with the sepsis policy. A sepsis screen would not be repeated prior to discharge, the treating consultant will review the patient based on their observations and NEWS2. As mentioned in the evidence of the ED Consultant during the inquest, it was noted that there were no other documented notes regarding this attendance on 28th December 2024. The documentation is not to the standard I would expect. I have spoken to the individual concerned about their documentation and they have reassured me that this has improved and detailed records are now being completed in line with their usual practice. It has also been escalated through their appraisal process.
Tameside and Glossop Integrated Care NHS Foundation Trus All staff in the Trust are aware of the importance of documentation, which you will know is governed by both the Nursing and Midwifery Council Code (2018) and by the General Medical Council. This is instilled in staff from the point of induction and throughout regular teaching sessions at divisional meetings held throughout the year like the junior doctor induction, Patient and Staff, Quality & Safety Forum (PASQASF), specialty meetings as well as the Legal Conference in September 2025. Additionally, there have been seven-minute briefings disseminated Trust wide dealing with the importance of documentation, in July and November
2025. The learning around this inquest and your concerns specifically on documentation was an agenda item for both Patient and Staff, Quality & Safety Forum and the Urgent and Emergency Care Quality and Safety Meeting both on 17th December 2025. These meetings were attended by Divisional Management, clinicians and nursing staff. In addition, the Trust conducts weekly training sessions for middle grade doctors in the Emergency Department every Thursday and documentation was a January 2026 agenda item. Training is also delivered to junior doctors at their induction. However, the Trust has observed that improvements are required to documentation, which will be overseen through the bi-monthly Clinical Effectiveness Group which is chaired by myself and is attended by the Chief Nurse, Deputy Chief Nurse, Associate Medical Directors, Divisional Nursing Directors, Clinical Directors, Divisional Director’s and the Deputy Chief Operating Officer. Through this group, I am commissioning a doctors’ documentation audit that will cover all aspects of documentation including ward rounds, post-take and discharge documentation which will be undertaken in summer 2026. As the Trust is currently compiling its annual audit programme, documenting the National and local audits that will be undertaken in 2026/27, the doctors’ documentation audit will form part of that audit programme. This audit programme will be reviewed at the Trust’s non-executive led Quality Committee in April
2026. In the meantime, the Emergency Department nursing Team Leader completes daily documentation audits which have Matron oversight, and any poor compliance is actioned immediately at the time of the audit Formalised handover documentation has also been implemented to ensure consistency in the handover of patient care and management plans. The Standard Operating Procedure has been updated to guide the assessment of patients being cared for in non-patient escalation areas (NPEA), to include an individual documented risk assessment and a team leader checklist. Furthermore, practice-based educators have redesigned the intentional rounding checklist. In November/December 2025, an audit of 35 patients nursed in non-patient escalation areas (NPEA) of the Emergency Department was conducted. This included reviewing notes and nursing documentation for 35 patients, focusing on: A-E assessment, patient safety checklists, nutrition and hydration, body map and skin integrity, NEWS2 policy followed, documentation of wristbands and personal hygiene needs. Whilst the electronic patient safety checklists are finalised by clinical informatics, the Clinical Practice Educator has developed a new patient safety checklist document to ensure all disciplines can record essential safety checks consistently, while maintaining registered nurse oversight and accountability.
NH Tameside and Glossop Integrated Care NHS Foundation Trus This audit has identified several challenges with documentation, particularly as patients are moved from high-pressure areas such as Rapid Assessment and Ambulatory Majors, where the high volume and rapid turnover of patients often result in minimal initial documentation. To address these challenges, several measures have been implemented including the new patient safety checklist in the NPEA. Matrons' walk-arounds have been revised to provide focused oversight on documentation quality and adherence to standards. The documentation audit process has also been redesigned, with responsibility assigned to the Band 7 nurse on both day and night shifts to maintain accountability and drive improvement In addition, clear documentation reminders have been placed on every nursing computer to reinforce expectations and support staff. I do hope that this letter provides you with further reassurance, however, should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact Legal Services on
Tameside and Glossop Integrated Care NHS Foundation Trus All staff in the Trust are aware of the importance of documentation, which you will know is governed by both the Nursing and Midwifery Council Code (2018) and by the General Medical Council. This is instilled in staff from the point of induction and throughout regular teaching sessions at divisional meetings held throughout the year like the junior doctor induction, Patient and Staff, Quality & Safety Forum (PASQASF), specialty meetings as well as the Legal Conference in September 2025. Additionally, there have been seven-minute briefings disseminated Trust wide dealing with the importance of documentation, in July and November
2025. The learning around this inquest and your concerns specifically on documentation was an agenda item for both Patient and Staff, Quality & Safety Forum and the Urgent and Emergency Care Quality and Safety Meeting both on 17th December 2025. These meetings were attended by Divisional Management, clinicians and nursing staff. In addition, the Trust conducts weekly training sessions for middle grade doctors in the Emergency Department every Thursday and documentation was a January 2026 agenda item. Training is also delivered to junior doctors at their induction. However, the Trust has observed that improvements are required to documentation, which will be overseen through the bi-monthly Clinical Effectiveness Group which is chaired by myself and is attended by the Chief Nurse, Deputy Chief Nurse, Associate Medical Directors, Divisional Nursing Directors, Clinical Directors, Divisional Director’s and the Deputy Chief Operating Officer. Through this group, I am commissioning a doctors’ documentation audit that will cover all aspects of documentation including ward rounds, post-take and discharge documentation which will be undertaken in summer 2026. As the Trust is currently compiling its annual audit programme, documenting the National and local audits that will be undertaken in 2026/27, the doctors’ documentation audit will form part of that audit programme. This audit programme will be reviewed at the Trust’s non-executive led Quality Committee in April
2026. In the meantime, the Emergency Department nursing Team Leader completes daily documentation audits which have Matron oversight, and any poor compliance is actioned immediately at the time of the audit Formalised handover documentation has also been implemented to ensure consistency in the handover of patient care and management plans. The Standard Operating Procedure has been updated to guide the assessment of patients being cared for in non-patient escalation areas (NPEA), to include an individual documented risk assessment and a team leader checklist. Furthermore, practice-based educators have redesigned the intentional rounding checklist. In November/December 2025, an audit of 35 patients nursed in non-patient escalation areas (NPEA) of the Emergency Department was conducted. This included reviewing notes and nursing documentation for 35 patients, focusing on: A-E assessment, patient safety checklists, nutrition and hydration, body map and skin integrity, NEWS2 policy followed, documentation of wristbands and personal hygiene needs. Whilst the electronic patient safety checklists are finalised by clinical informatics, the Clinical Practice Educator has developed a new patient safety checklist document to ensure all disciplines can record essential safety checks consistently, while maintaining registered nurse oversight and accountability.
NH Tameside and Glossop Integrated Care NHS Foundation Trus This audit has identified several challenges with documentation, particularly as patients are moved from high-pressure areas such as Rapid Assessment and Ambulatory Majors, where the high volume and rapid turnover of patients often result in minimal initial documentation. To address these challenges, several measures have been implemented including the new patient safety checklist in the NPEA. Matrons' walk-arounds have been revised to provide focused oversight on documentation quality and adherence to standards. The documentation audit process has also been redesigned, with responsibility assigned to the Band 7 nurse on both day and night shifts to maintain accountability and drive improvement In addition, clear documentation reminders have been placed on every nursing computer to reinforce expectations and support staff. I do hope that this letter provides you with further reassurance, however, should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact Legal Services on